Article featured on Becker’s Healthcare.
When transitions of care break down, patients feel it through repeated histories, fragmented communication, and preventable returns to the hospital. For patients with chronic illness, movement between acute and post-acute settings can become a costly, exhausting cycle that impacts outcomes, experience, and resources.
It doesn’t have to be that way.
Transitions of care represent one of healthcare’s greatest opportunities to strengthen collaboration, communication and continuity, and to deliver truly patient-centered care.
Why transitions are challenging
Moving patients across acute and post-acute settings requires coordination across a complex network of clinicians and administrators. Connecting that network consistently remains a persistent challenge.
Technology plays a critical role. When optimized, it strengthens continuity. When limited, the consequences are significant.
“Technological limitations that hinder access to patient medical records across different care settings can lead to medication errors, misdiagnoses, increased costs, and confusion about treatment plans,” says Teizu Wolokolie, MD, Regional Medical Director, Post-Acute Care.
Communication gaps further complicate transitions. “The real challenge lies in making sure that the whole network is connected or at least available so that there could always be a provider to be called up, either electronically, via chat or telephonically,” says Hammad Rizvi, DO, Hospitalist, Senior Vice President, Northeast Group.
Each care setting operates with its own processes and pressures. Without intentional collaboration, healthcare can become siloed limiting shared understanding and slowing coordinated decision-making.
“I’ve seen patients consistently experience better outcomes when there is effective communication between transferring and receiving care providers,” says Wolokolie.
The connection to rehospitalization
For patients with chronic conditions, fragmented transitions often contribute to cycles of rehospitalization.
“Chronically ill patients may be readmitted for the same circumstances multiple times,” says Rizvi. “If teams in different settings can connect, even with a complex patient case, they could handle it at the lowest care level possible which would promote better patient care.”
Reducing rehospitalization requires coordinated care at every stage of the patient journey. According to Wolokolie, this includes follow-up with specialists and primary care providers, medication reconciliation and meaningful patient and family education at discharge.
Avoiding even one unnecessary hospitalization improves outcomes and reduces overall cost of care.
What strong transitions make possible
Care transitions are more than operational handoffs. They are defining moments in the patient experience.
“If you can have those providers who know that patient well, you can connect the dots and provide better care for that patient,” says Rizvi.
Strong transitions enhance patient safety, strengthen collaboration, and improve resource utilization. “Effective care transitions help prevent common errors like missed appointments, misdiagnoses and medication disparities while minimizing redundancy in care and avoidable re-hospitalizations,” says Wolokolie.
At their best, transitions keep the patient at the center of the care plan.
Strengthening collaboration across the continuum
Improving transitions requires more than process — it requires relationships.
“It’s always helpful to have relationships in order to coordinate care,” says Rizvi. “It’s much easier if you know the person you’re transitioning a patient to.”
Teams must communicate clearly and prepare patients for the full care continuum.
“You need to know the patient’s whole story or at least a particular part of the story to treat them,” says Rizvi. “If you can’t communicate well, you may lose the ability to have the patient at the center of the care plan.”
How TeamHealth strengthens care transitions
TeamHealth is uniquely positioned to support successful transitions because of our footprint across the full care continuum. Our scale enables efficient communication, coordinated resources, and meaningful cross-setting collaboration.
“At TeamHealth, we do our best to reassure the patient by familiarizing them with the medical team and maintaining an open line of communication with their providers,” says Wolokolie. “This enhances the patient’s experience and reduces the likelihood of an unnecessary transfer back to the hospital due to patient requests.”
Cross-setting experience builds perspective. “As a hospitalist, sometimes you assume it would be easier to care for patients at a SNF,” says Rizvi. “But when you enter that setting, you appreciate the unique processes and resources more.”
With over 15,000 clinicians serving patients across the full care continuum, TeamHealth brings the depth, breadth, and integration required to strengthen patient-centered transitions which improves outcomes while supporting operational performance. Connect with our team.
